HomeMy WebLinkAboutLOMA ESTATES BLK 1 LT 10
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
Pump Installation Log
Well Drilling Permit Number: _______________ Date of Issue: ____-____-____
Parcel Identification Number: ____-____-____
Legal Description Block Lot Property Owner Name & Address:
Pump Installation Date: _____-_____-_____
Pump Intake Depth Below Top of Well Casing: __________ feet
Pump Manufacturer’s Name: ___________________________ Pump
Model: _____________________________________
Pump Size: ____________hp
Pitless Adapter Burial Depth: _________ feet
Pitless Adapter Manufacturer’s Name: ________________________
Pitless Adapter Installer: ____________________________
Well Disinfected Upon Completion? XX Yes No
Method of Disinfection: _____________________________
Comments:
Pump Installer Name: __________________________________
Company: ___________________________________________
Mailing Address: ______________________________________
City: ___________________ State: __________Zip: _________
Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation.
,:-~-, MUNICIPALITY OF ANCHORAGE / .
DL ,RTMENT OF HEALTH AND HUMAN SER 5ES
' Environmental Health Division
" 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name DISTANCES
SEPTIC ABSORPTION
Address WELL (~
~-Off L~ ~-/¢t ~¢~d /9'7 TANK FIELD
Phone(s) ~G/~--C~ J ~ ~ ¢~ Permlt~No.¢~ ¢)~ NO. of~drooms WELL ) (¢O ' ~ foO '
Lot J Block / Subdiwsion
Township, Range, Section
~'~c 3 %ll N R ~ ~ %,H. AS-.UlLTDIAORA~(Showlocat,onofweH, septic system, propertyhnes, lounda,,o..
dnveway, water bodies, etc.)
~ SEPTIC ~ HOLDING ~ ~
TYPE OF SYSTEM ~ ~ ~ ~ >
~TRENCH ~ BED ~ W. DRAIN ~ OTHER _~ J 0 ¢' ~J
Depth to pipe bottom from Total depth from original 9rede
Total abs;~hon area L~ Distance between lines ~ ~i f rfc '¢ ~fB~ -~ .... ~ ~
~ FT
Number ol lines Soil rabng Pipe material
- i~O~ '-~ate installed
WELLS fiG~ M ~.~ ~
~ PRIVATE ~ OTHER fidentifv)
ClassUicahon (A,B,C) Total Depth F~ Cased to FT
Installe~ Date Installed:
Inspections Pedormed by: ~
Municipal and Stale guidelines in effect 0nthis date: ~/ I /'~' % ~. ~ ~ - o~o,~ . ,.~ '
Hearth Depa.ment Approval:Date: ~:~:~. · "'..~~
O~E) O O O O O
13::~E, I3:: 13::: IZ:
~o ~o o o o o o
i, lI. ii I~- i, i, ii
0 0 0 0 0 0 0
ii ii ii ii LL i, ii
GLIB:I) I V I S I (]lq: LOMA EF:3T.
· %EC:T i ON:~ 3 'TOWNSH I
47()()0 -'.'.SD,, F:'T~ OR ACRES
,..J]T, :[0
.1. IN RANGE: 3W
:SLOCI<: ~
L..~.s'Led belc,,..~ are the c)ptioi'-~s ava:i, labl,:a 'Lo you J.n c:Je~-:i, cjr~irp[:[l your sept:i.c
., , ~
Df:'iZPTH TO F:'IPliE BO'T"TOM (F'T:)
GRAVE:[... :O,Si:F:'TH (I:::T.)
TO'I'AL DEF:"I"H (F:'T,,
(]:JF~AgEL. WIDTH (F'T.)
GRAVE[_. VOLLJME (CL],, YDS. )
]"ANt::: SI ZE (GAL..S
SO ]: [... RATING
~.,~. TAN].::. MUST HAVE A'T L..L:.!:AST TWO COMPAR'I"I~.ENT}~
forth by~.. ..... ~::~ Mun:Lr"ipal:i."~..x ..... ,..,,~' And-iorage.. (MOA) arid 'Lhe Sta'Le of A].aska.
&u-id :i. I'] (::oilli:) ]. :i. ~r')c:E, b~ J. 'Ih '[h6~ -'b ..... .. ' .
]. tgJ.].]. ~:U. JII~..H'G:~ tO ,?,ll !q[:]A ~d3d ~:t..~:~.r:..: C)~' a' .:,c~L-.~, PE~qL[il'E.)rfiG)I'i'IL~ ~'(::H" th(.z' ,:;~:,'I' back
[J' Lu-ld~l"stand tha'L t.'- ' s . " " "~'
~, ~ I:)E'P~]J.'t. :[~, va]. icj ¥ ol- a max imLtm .. , 3 [)~.~,c:lr'-c)oms a.F~d
:[I::: A L..:[I:::'T S"FATION IS :[IqS'I"AI..J...ED !N AN AREA DOVERED BY MOA BU]:t....D!NG CODES,
THEN (I) AN ELEC, TF~ICAL F:'ERMIT AND INSF:'EC]"ION I¥1UST BE OB't'A]:NE:[)~ (2) AS"-BUiL. TSi
WILl.... NO]- BE AF:'F'ROVED WIT!4[]U'T AI% EL. EC:TRICAL. tNSPEC:TION RI~EP[)!:C~"; AND (3) '!"HE:
ELECTR I CAL. W[]F?.I< P'!L!ST :81~E DONE BY A L..!CENSE[D !E[...ECTR I C I AN,,
L),-,i i l::.:
s :.: ~:.:~ N E D"] ..........................................................................................
ISSUED BY l..,~..i f ,..:. ~ ~ ~
Flat~5-~ Te-cl~hic&I Service~
"I4530 Echo Slreet
~nchorage, AIaska 99516
MUNICIPALITY OF ANCHORAGI=
DEPT. OF HEALTH &
ENV RONMEN'TAL PROTECTION
~IUL 2.41986
~ RECEIVED
~c I "FE P~A.N
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG -- PERCOLATION TEST
tl. 0~
SOILS LOG
[] PERCOLATION
TEST
RE.EORMEE, FOR:
DATE PERFORMED: 7
LEGAL DESCRIPTION:
2
3
4
7
8
SLOPE
SITE PLAN
i"
10
11
12
13
14
15
16
17
18
19
20-
WAS GROUND WATER S
ENCOUNTERED? [\[ O L
E
IF YES, AT WHAT 7 [7-V /~¢'
Gross Net Depth to Net
Reading Date
Time Time Water Drop
THEODORE F. MOORE
'"'PERCOLATION RATE (minutes/inch)
~ TEST RUN BETWEEN FT AN~ FT
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST
PERCOLATION
TEST
DATE PERFORMED:
LEGAL DESCRIPTION:
2
4
§
7
8
814
11
12
13
14.
15
16
17
18-
19-
2O
COMMENTS
SLOPE
THEODORE F, MOORE
% CE- 3589
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date
Time Time Water Drop
t
PERFORMED BY: .]~'1~,,,~ ~")~1~ T~:4. b-,d' CERTIFIED BY:~
.PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN , FT AND -- FT
!
DATE: 7fz"//8~"
72-008 (6/79)
' , ' ' [] SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST
PERCOLATION
TEST
PEREORMED EOR:
LEGAL DESCRIPTION:
o,¢- rt
2 --
3
5
6
7
DATE PERFORMED:
SLOPE
[
I I Itll
I I
I I
SITE PLAN
lO
12
13
14
15
16
17
18
19
2O
THEODORE F.
CE - 3589
WAS GROUND WATER S
ENCOUNTERED? ~'~ L
O
P
IF YES, AT WHAT il E
DEPTH? '~
G~oss Net ) Depth to Drop ~"'h)
Reading Date Time Time (~;n Water
PERCOLATION RATE ..~ (minutes/inch)
TEST RUN BETWEEN ~'~ FT AND q;O . FT
$25 '"L' STREET
ANCHORAGE, ALASKA 99501
..... ~o~-4,1 1
.~f:CPGE M. SULLIVAN,
December 31, 1979
John Simpson
Star Route A Box 474-S
Anchorage, Alaska 99507
Permit ~ 790031
Subject: Lot 10 Block 1 Loma Estates Subdivision
A permit issued by this department for well and/or sewer
system has expired.
Per~its are issued on a calendar year basis, as stated on
the permit, by authority of Municipal ordinance.
If you have drilled the well, a well log should be sent
to this department to document the installation date.
If an engineer has inspected the installation of the
on-site sewer system, please have them send us the as-builts
for our files.
If there are any further questions, please contact this
office at 264-4720.
LNB/ljw
enc: Copy of Permit
F'ERMI T NO.
DE,PRRTMENT Or- .iERLTH RND ENYIRONMENTRL
825 "L'" STF:'.EET, RNC:HORRGE., 8K. 99501.
264-4720
RPPL. t CANT
LOCRT I ON
LEGflI_
JOHN SIMF'SON
BETTY ..TERN
L'.I. 0 B':L LOMFI E_,T
SRFI ~" -'=
I_OT ::, I
5400t.'] '~L.]IJF:IRE F'EET
'- - TF. EN _.Fi
TYF'E OF =,UIL. ~E,=,_RE, fI.N SYSTEM IX: ' "
I"IR>::IMLIM NLIMBER OF E:EDROOMS =
:Eh:IL RRTING ,'S;~ FT,.'E,R)= t7.0
THE REE!IJIRED SIZE OF THE SOIL ABSORPTION SYSTEM IX:
[:. [E F" T' H = :L ~ L_ E.:' P-.I n3 T Fl == --~- __.7_.: n3 F..: fa %-" E:.: L. £:" E F" T' ~-~ ==
"['FIE LENG'rH DIMENSION IX THE LENGTH (IH FEET) OF THE TRENC:FI OR DRRINFIEL. D.
THE DEPTH OF R TRENCH OR PIT IX THE DIS;'f'RNCE BETWEEN ]'HE SURFRCE OF TFIE
GROUND RND TFIE BOTTOM OF THE EXCRVRTtON ,:'.IN FEET).
"['HERE IX NO SET WIDTH FOR TRENCHES.
THE GRRVEL DEPTH IX THE MINIMUH DEPTH OF GRR',/EL BETI4EEN THE OLITFRLL PIPE
FIND THE BOTTOM OF THE EXCRVRTION ,:;IN FEET::,.
F'ERMIT RPPLIC:FINT HRS THE REc, FUNz, IBILITT TO INFORM THIS DEF'FIRTMENT E:,I..IR~NG "['HE
..... r'r:._r=.~.~t AND ]'HE:
IN'-qTFILLFI"fION INSF'EF:TIFtN'~ OF RNY NELL. S RDJRCENT TO THIS .... F~''~'~ ....
NUMBER OF F..'E:,I[.EN_.E:, THRT THE NELL WIL. L SEF.:',,,'E.
BFIE:KFILLING OF RNY _-t=TEH NITHOUT FINRL INSPECTION RN[:' RF'PROVRI_ E:Y THIS
E:,IEPRRTf~ENT WILL E:E 2.;LIB.TECT TO PROSECUTION.
MINIMUM DISTRNCE 8ETHEEN R WELL RND RNY ON-SITE SEWRGE [.',ISPOSRL SYSTEM IS
· ~.';.iF~ A PF.:I'v'ATE WE--L_L.~
~ FEET FOR _
1.JO TO 2::00 FEET FROM FI F'UBL~C NELL DEPENDING LIPON THE TYF'E OF PUBL,~C WELl_.
NELL LOGS RRE REQUIRED RND MUST BE'. RETLRNED TO THE DEPRRTMENT 1,4~TH~N ]:O DRYS
OF THE NELL COMPLETION.
O'I-HER REQUIREMEN'rS MRY RPPLY. SPECIFICATIONS RND CONSTRUCTION DIFIGRRMS RRE
RVRILRBLE TO INSURE PROPER INSTRLLRTION.
I _.~: ,../~.r t THFIT
t: I RM FAMILIRF.: WITH THE REg!LIIREMENTS FOR ON-SITE SEWERS FIND I.,~EL..Li~ RS SET
FORTH BY THE MUNICIF'RLITY OF FINCHORRGE.
~: I HILL INSTRLL THE :,~:,FEI1 IN RCCOR[)FINCE WITH THE CO[:,ES.
3:: I UN[:,ERSTRND THRT THE ON-SITE~ENER SYSTEM MFIY REQUIRE ENLFiRGEMENT IF THE
RESIDENCE IS REMO[:'E~ T~INCL~ MORE TFIRN 3: E:EDROOMS.
//
GREATER ANCHORAG[ AREA BOROUGH
DEPARTMENT OF ENVIRONMENTAL QUALITY
3330 "C" Street
ANCHORAGE, ALASKA 99503
Legal Description: Lot /0 Block
This Form Reports Soils Log
Soil
Depth
Feet
Dated Performed /./::
I Subdivision ~-~-,~ ~':~:
Percolation Test
Test Must Be Logged To 4' Below Proposed Seepage System - ·
2--
3--
4--
§--
7--
8--
9--
10-
ll--
12--
13--
14--
Soil Characteristics
Was Ground Water Encountered?
If Yes, At What Depth?
Reading Date Gross Time Net Time Depth to H20 .':~fle, ufos.
, .(:~-) :...
! ///~..,~ '4;4:. - 4,':: ....t~ ,,I,~ I,IP -.:,~:" . :-:'::. . .
, ,1 ,
.~. , ~, ~ ~ *~ ~ ~. ~'- ~,~/ · .~ .
: -.1 ~: ~: - ~.: m /, / ~ '- ~, ¢? ., _ I,i, ,~::~, zl..,:
Percolation Rate O.P ~ Minu'~e///,,:/:
Proposed Installation: Seepage Pit Drain Field
Depth of Inlet Depth to Bottom of'-Pit Or Trench
"-
/
.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name ~/~e~ ~-c4~ Telephone: Home ;~ ~/5- - 7.J'C~8 Business
ApplicantAddress I~o ~ II It ~'¢" ,~ ~ ~c~or'~e'~ /t-I'~
(c) Applicant is (check one): Lending Institution []; Owner/builder []; Buyer I-I; Other [] (explain);
(d) Lending Institution ..~¢cc~r"¢ IL~v N~J'~c,,~¢l ~,'~ Telephone
Address ~' ¥1 ~¢z-/- 7'"~-Jor Rr.Z~ /~n¢/~orc~(/¢,5,/ ,,,~-I~' ~1~,.¢ O..~
(e) Real Estate Company and Agent hi, A.
Address
(f)
Telephone
Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family [] Multi-Family []
Number of Bedrooms ~
Other
WATER SUPPLY
Individual Well [] Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL ~ ~
Onsite [] Public [] ' Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
PRnR I c~f 3 72-025 (11/84)
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm I F (~ ~ re~ ~C~ ~ ~; C ~ Telephone
Address I~t~' ~EclI~ ~ ~ ~che~ ~
Date I~ ~a~ ~ ~
Engineer's Seal
DHEP APPROVAL'
¥;'~ ,~','i~- .-~Y~- "
/9, ();? !./'/?/ . ~' .. .(' ~; Date
Approved '~? ' '
. Dmapprov~d Conditional
Terms of Conditional Approval
CAUTION'
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: ~.o/~
WELL DATA
Well Classification ~C~'~'¢ ~¢
Well Log Present (Y/N) ~
Total Depth ~0,~4" ' Cased to 8~¢'
Static Water Level 70 '
Casing Height Above Ground ~ ~
Electrical Wiring in Conduit (Y/N) ~'
IfA, B, C, D.E.C. Approved (Y/N)
Date Completed ~' ,/ 7 ! gU'" Yield
Depth of Grouting ~, ,~-
Pump Set At Cf,~/~
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots ~ tOO
; On Adjoining Lots ~ ~'O~
Separation Distances from Well:
To Septic/Holding Tank on Lot I ~- ~'
To Nearest Edge of Absorption Field on Lot [¥¥ a
To Nearest Public Sewer Line N,,~- To Nearest Public Sewer
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
~. ~, To Nearest Sewer Service Line on Lot
tc'(~/'~'u/~ -*r¢c/~,!¢c~/ 5~",~¢~-,~ ;Date
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed ~'/'/{~'
Standpipes (Y/N) ~'
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N) ~h/J.
Separation Distances from Septic/Holding Tank:
To Water-Supply Well ,'f ~' ~
To Property Line ~-~
To Water Main/Service Line ~/l.
Size lO00 ¢~[ No. of Compartments
Air-tight Caps (Y/N) ~' Foundation Cleanout (Y/N)
N Date Last Pumped ,N.,,'I.
~IV. ~. ; for
Temporary Holding Tank Permit (Y/N) N, ,~.
Course ~ too°
To Building Foundation ~4~ ~
To Disposal Field 1 1 *
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date installed ~'/'1 / ~u~'
Width of Field ~g-'
Square Feet of Absorption Area
Depression over Field (Y/N) IN
Results of Last Adequacy Test t4, /.J.
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line ~¢;2 ~
To Existing or Abandoned System on
; On Adjoining Lots ~, "~O ~
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
To Cutbank (if present)
D, LIFT STATION ~f, ,.4.
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~~ ~' ~ Date
,Cd'- o~-~_
MOA No.
Company
Receipt No.
Date of Payment
Amount:$ ~-,
Page 2 of 2
72-026 (11/84)
Engineer's Seal
